Sometimes, the IOL can dislocate after surgery and in the case of a three-piece IOL, we can easily suture the haptics to the posterior surface of the iris. This surgery is performed by a resident surgeon in my program, Elisha Garg MD, who does a great job with this challenging case. The total surgical time is about 30 minutes, though the video has been edited down to 10 minutes for teaching efficiency. This is a technique that every cataract surgeon can learn to perform.
This patient had cataract surgery performed with the complication of a ruptured posterior capsule. A three-piece, hydro-phobic, mono-focal, acrylic IOL was placed in the sulcus and the patient did well initially. However, after a while the IOL became dislocated and it was determined that there was some capsular support but not a sufficient amount for long-term stability.
The critical first step of the surgery is to make sure that the IOL does not fall back into the vitreous cavity. You do not want the pupil widely dilated, rather you want it to be 5 mm or less in diameter. The optic of the IOL should be prolapsed into the anterior chamber and held above the iris while the haptics are below the iris in the sulcus.
Multiple paracentesis incisions can be made for access. There is no need for a large, main incision. Viscoelastic is put behind the IOL optic to help support it and then in the anterior chamber to protect the corneal endothelium and prevent it from collapsing.
Using the spatula or other instrument to tent up the optic will allow you to see the outline of the haptics and it makes suturing them easier. Using a 10-0 (or 9-0) Prolene with a long needle (curved or straight), a pass is made in the mid-periphery of the iris, not near the pupil margin. At this point the second suture can be passed around the other haptic.
Before cinching down the knots (I recommend a 3-1-1-1 knot), be sure to pull the pupil margin centrally to avoid incarcerating excessive iris tissue in the suture. This is the key to avoiding the ovoid pupil. As you can see in the post-op pic, the pupil is still reasonably round.
One final note: in an eye with a prior vitrectomy (anterior or posterior), iris fixation of the IOL is good if there is at least some degree of capsular rim support. If there is zero capsular support, just relying on these two sutures may not be sufficient to hold the IOL and the IOL may dislocate after just a few years. The IOLs tend to slip out of the knots and the extra weight of the IOL can cause the iris to become hyper-mobile, leading to further issues. In these eyes with zero capsular support, a scleral-fixated IOL may be a better option.
Click below to learn how to suture an IOL to the iris: